Soft tissue augmentation is a common procedure performed by dermatologists to address many patient concerns such as aging, loss of volume, scarring, tear trough hollowing, lip thinning, asymmetry, and hand rejuvenation.
Compared with cosmetic surgery, soft tissue augmentation is an affordable minimally-invasive procedure with little to no downtime. In the 2016 report log by the American Society of Plastic Surgery, soft tissue augmentation with fillers ranked second in number of cosmetic procedures after botulinum toxin type A injection with more than 2.6 million treatments performed.1 Even though soft tissue augmentation is a safe procedure, it can still present complications. In this article, we present a case of a patient with a nodule on the nasolabial fold after injection of a hyaluronic acid (HA) filler.
Case
A 46-year-old woman presented to our practice with an erythematous nodule on the left nasolabial fold after receiving an HA (Restylane) injection 2 months prior by an injector at another practice. The patient stated that 2 weeks after the procedure, she noticed the area became progressively swollen and painful and drained a yellowish discharge. She went to an urgent care center and was given a 2-week course of clindamycin and amoxicillin clavulanic that decreased the size of the nodule and improved the pain. However, 2 days after finishing the antibiotics, the area became swollen, painful, and started to drain again. She then consulted another practitioner who prescribed oral ciprofloxacin for 10 days followed by intramuscular ceftriaxone (Rocephin) and vancomycin with the same response.
Figures 1. On physical exam, the patient presented with a 1-cm hyperpigmented, well-demarcated, erythematous nodule on the left nasolabial fold with 2 additional superiorly placed 4-mm nodules.
The patient had onabotulinumtoxin A (Botox) in the past but denied the use of previous fillers. She denied any medical problems or allergies. On physical exam, the patient presented with a 1-cm hyperpigmented, well-demarcated, erythematous nodule on the left nasolabial fold with 2 additional superiorly placed 4-mm nodules (Figure 1). No discharge was present but the area was very tender to palpation. Incision and drainage was attempted and was unsuccessful. A bacterial culture was taken from the area which was negative for growth. An injection of 0.1 cc of 10 mg/cc intralesional triamcinolone was administered followed by 0.1 cc of hyaluronidase. The patient was also given cephalexin, 500 mg twice daily for 2 weeks. Upon follow-up 3 weeks later, the nodules resolved with no pain or swelling of the area. Only postinflammatory hyperpigmentation was noted. This will be addressed in her next appointment in 1 month (Figure 2).
Figures 2. Upon follow-up 3 weeks later, the nodules resolved with no pain or swelling of the area. Only postinflammatory hyperpigmentation was noted which will be addressed in her next appointment in 1 month.
Discussion
Soft tissue augmentation is a very desirable cosmetic procedure because it is fast, effective, and has relatively few complications. Because these procedures are increasing in numbers, the dermatologist should be familiar with the potential side effects and how to prevent and to treat them to improve patient safety and satisfaction. Early complications include edema, injection associated discomfort, bruising, and erythema, and they are usually self-limited, resolving within 1 week.2
Among the most serious acute complications are the ones related to vascular occlusion and nerve damage. They can be avoided with skillful technique and knowledge of the anatomic area where the procedure is performed.3
Another complication that can be seen after soft tissue augmentation is nodule formation. The etiology of nodules can can be divided into 2 categories: inflammatory and noninflammatory. Inflammatory nodules are either a result of an infection (biofilms) or foreign body granulomas. Noninflammatory nodules are secondary to the material injected too superficially and are evident shortly after the procedure. Hyaluronidase is the treatment of choice if the filler is HA. If other material is used, they can respond to vigorous massage or potentially extrusion of the material.4 Even though inflammatory nodules have 2 different etiologies, it can be difficult to elucidate its real cause. Foreign body granulomas are an uncommon complication of this procedure, with a rate of approximately 0.4% for HAs and 0.001% for calcium hydroxyapatite.5
Typically, they are treated with intralesional steroids and hyaluronidase with good resolution. If no clinical response is seen, a biofilm should be suspected and the patient should be placed on broad-spectrum antibiotics for a minimum of 4 weeks that include quinolones and macrolides.4 Biofilms are microenvironments that are formed around the filler by the adjacent bacteria, they elaborate extracellular matrix of exopolysaccharides that also include HA. The bacteria adhere to this matrix protecting it from antibiotics.6,7 When a biofilm is present, it usually will not render any result on the bacterial culture making the diagnosis difficult. Besides antibiotics, hyaluronidase should be used in these cases along with antibiotics to disrupt the protective microenvironment.7
Our Patient
In our patient, even though the nodules had been there for 2 months, they resolved with intralesional triamcinolone and hyaluronidase, making the diagnosis of noninflammatory nodules more plausible. To prevent biofilms, it is critical to undergo thorough cleaning of the patient’s face before the procedure, avoid injection in areas that may be swollen or infected, reduce the amount of needle sticks, and use the smallest sized needle.3
Soft tissue augmentation is a common procedure for dermatologists. Serious complications are very uncommon, however, knowledge of how to prevent and to treat them is paramount.
Dr Correa-Selm is a micrographic surgery and procedural dermatology fellow at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Dr. Rogachefsky is the Program Director of the ACGME-approved Micrographic Surgery and Procedural Dermatology Fellowship and practicing dermatologist at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Dr Lee is director of the ACGME-approved micrographic surgery and procedural dermatology fellowship and a practicing dermatologist at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Disclosure: The authors report no relevant financial relationships.
References
1. Plastic surgery statistics. American Society of Plastic Surgeons website. https://www.plasticsurgery.org/news/plastic-surgery-statistics. Accessed June 22, 2017.
2. Wagner RD, Fakhro A, Cox JA, Izaddoost SA. Etiology, prevention, and management of infectious complications of dermal fillers. Semin Plast Surg. 2016;30(2):83-86.
3. Bailey SH, Cohen JL, Kenkel JM. Etiology, prevention, and treatment of dermal filler complications. Aesthet Surg J. 2011;31(1):110-1121.
4. Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clin Cosmet Investig Dermatol. 2013;12(6):295-316.
5. Lolis M, Dunbar SW, Goldberg DJ, Hansen TJ, MacFarlane DF. Patient safety in procedural dermatology: Part II. Safety related to cosmetic procedures. J Am Acad Dermatol. 2015;73(1):15-24.
6. DeLorenzi C. Complications of injectable fillers, part I. Aesthet Surg J. 2013;33(4):561-575.
7. Beer K, Avelar R. Relationship between delayed reactions to dermal fillers and biofilms: facts and considerations. Dermatol Surg. 2014;40(11):1175-1179.
Soft tissue augmentation is a common procedure performed by dermatologists to address many patient concerns such as aging, loss of volume, scarring, tear trough hollowing, lip thinning, asymmetry, and hand rejuvenation.
Compared with cosmetic surgery, soft tissue augmentation is an affordable minimally-invasive procedure with little to no downtime. In the 2016 report log by the American Society of Plastic Surgery, soft tissue augmentation with fillers ranked second in number of cosmetic procedures after botulinum toxin type A injection with more than 2.6 million treatments performed.1 Even though soft tissue augmentation is a safe procedure, it can still present complications. In this article, we present a case of a patient with a nodule on the nasolabial fold after injection of a hyaluronic acid (HA) filler.
Case
A 46-year-old woman presented to our practice with an erythematous nodule on the left nasolabial fold after receiving an HA (Restylane) injection 2 months prior by an injector at another practice. The patient stated that 2 weeks after the procedure, she noticed the area became progressively swollen and painful and drained a yellowish discharge. She went to an urgent care center and was given a 2-week course of clindamycin and amoxicillin clavulanic that decreased the size of the nodule and improved the pain. However, 2 days after finishing the antibiotics, the area became swollen, painful, and started to drain again. She then consulted another practitioner who prescribed oral ciprofloxacin for 10 days followed by intramuscular ceftriaxone (Rocephin) and vancomycin with the same response.
Figures 1. On physical exam, the patient presented with a 1-cm hyperpigmented, well-demarcated, erythematous nodule on the left nasolabial fold with 2 additional superiorly placed 4-mm nodules.
The patient had onabotulinumtoxin A (Botox) in the past but denied the use of previous fillers. She denied any medical problems or allergies. On physical exam, the patient presented with a 1-cm hyperpigmented, well-demarcated, erythematous nodule on the left nasolabial fold with 2 additional superiorly placed 4-mm nodules (Figure 1). No discharge was present but the area was very tender to palpation. Incision and drainage was attempted and was unsuccessful. A bacterial culture was taken from the area which was negative for growth. An injection of 0.1 cc of 10 mg/cc intralesional triamcinolone was administered followed by 0.1 cc of hyaluronidase. The patient was also given cephalexin, 500 mg twice daily for 2 weeks. Upon follow-up 3 weeks later, the nodules resolved with no pain or swelling of the area. Only postinflammatory hyperpigmentation was noted. This will be addressed in her next appointment in 1 month (Figure 2).
Figures 2. Upon follow-up 3 weeks later, the nodules resolved with no pain or swelling of the area. Only postinflammatory hyperpigmentation was noted which will be addressed in her next appointment in 1 month.
Discussion
Soft tissue augmentation is a very desirable cosmetic procedure because it is fast, effective, and has relatively few complications. Because these procedures are increasing in numbers, the dermatologist should be familiar with the potential side effects and how to prevent and to treat them to improve patient safety and satisfaction. Early complications include edema, injection associated discomfort, bruising, and erythema, and they are usually self-limited, resolving within 1 week.2
Among the most serious acute complications are the ones related to vascular occlusion and nerve damage. They can be avoided with skillful technique and knowledge of the anatomic area where the procedure is performed.3
Another complication that can be seen after soft tissue augmentation is nodule formation. The etiology of nodules can can be divided into 2 categories: inflammatory and noninflammatory. Inflammatory nodules are either a result of an infection (biofilms) or foreign body granulomas. Noninflammatory nodules are secondary to the material injected too superficially and are evident shortly after the procedure. Hyaluronidase is the treatment of choice if the filler is HA. If other material is used, they can respond to vigorous massage or potentially extrusion of the material.4 Even though inflammatory nodules have 2 different etiologies, it can be difficult to elucidate its real cause. Foreign body granulomas are an uncommon complication of this procedure, with a rate of approximately 0.4% for HAs and 0.001% for calcium hydroxyapatite.5
Typically, they are treated with intralesional steroids and hyaluronidase with good resolution. If no clinical response is seen, a biofilm should be suspected and the patient should be placed on broad-spectrum antibiotics for a minimum of 4 weeks that include quinolones and macrolides.4 Biofilms are microenvironments that are formed around the filler by the adjacent bacteria, they elaborate extracellular matrix of exopolysaccharides that also include HA. The bacteria adhere to this matrix protecting it from antibiotics.6,7 When a biofilm is present, it usually will not render any result on the bacterial culture making the diagnosis difficult. Besides antibiotics, hyaluronidase should be used in these cases along with antibiotics to disrupt the protective microenvironment.7
Our Patient
In our patient, even though the nodules had been there for 2 months, they resolved with intralesional triamcinolone and hyaluronidase, making the diagnosis of noninflammatory nodules more plausible. To prevent biofilms, it is critical to undergo thorough cleaning of the patient’s face before the procedure, avoid injection in areas that may be swollen or infected, reduce the amount of needle sticks, and use the smallest sized needle.3
Soft tissue augmentation is a common procedure for dermatologists. Serious complications are very uncommon, however, knowledge of how to prevent and to treat them is paramount.
Dr Correa-Selm is a micrographic surgery and procedural dermatology fellow at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Dr. Rogachefsky is the Program Director of the ACGME-approved Micrographic Surgery and Procedural Dermatology Fellowship and practicing dermatologist at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Dr Lee is director of the ACGME-approved micrographic surgery and procedural dermatology fellowship and a practicing dermatologist at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Disclosure: The authors report no relevant financial relationships.
References
1. Plastic surgery statistics. American Society of Plastic Surgeons website. https://www.plasticsurgery.org/news/plastic-surgery-statistics. Accessed June 22, 2017.
2. Wagner RD, Fakhro A, Cox JA, Izaddoost SA. Etiology, prevention, and management of infectious complications of dermal fillers. Semin Plast Surg. 2016;30(2):83-86.
3. Bailey SH, Cohen JL, Kenkel JM. Etiology, prevention, and treatment of dermal filler complications. Aesthet Surg J. 2011;31(1):110-1121.
4. Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clin Cosmet Investig Dermatol. 2013;12(6):295-316.
5. Lolis M, Dunbar SW, Goldberg DJ, Hansen TJ, MacFarlane DF. Patient safety in procedural dermatology: Part II. Safety related to cosmetic procedures. J Am Acad Dermatol. 2015;73(1):15-24.
6. DeLorenzi C. Complications of injectable fillers, part I. Aesthet Surg J. 2013;33(4):561-575.
7. Beer K, Avelar R. Relationship between delayed reactions to dermal fillers and biofilms: facts and considerations. Dermatol Surg. 2014;40(11):1175-1179.
Soft tissue augmentation is a common procedure performed by dermatologists to address many patient concerns such as aging, loss of volume, scarring, tear trough hollowing, lip thinning, asymmetry, and hand rejuvenation.
Compared with cosmetic surgery, soft tissue augmentation is an affordable minimally-invasive procedure with little to no downtime. In the 2016 report log by the American Society of Plastic Surgery, soft tissue augmentation with fillers ranked second in number of cosmetic procedures after botulinum toxin type A injection with more than 2.6 million treatments performed.1 Even though soft tissue augmentation is a safe procedure, it can still present complications. In this article, we present a case of a patient with a nodule on the nasolabial fold after injection of a hyaluronic acid (HA) filler.
Case
A 46-year-old woman presented to our practice with an erythematous nodule on the left nasolabial fold after receiving an HA (Restylane) injection 2 months prior by an injector at another practice. The patient stated that 2 weeks after the procedure, she noticed the area became progressively swollen and painful and drained a yellowish discharge. She went to an urgent care center and was given a 2-week course of clindamycin and amoxicillin clavulanic that decreased the size of the nodule and improved the pain. However, 2 days after finishing the antibiotics, the area became swollen, painful, and started to drain again. She then consulted another practitioner who prescribed oral ciprofloxacin for 10 days followed by intramuscular ceftriaxone (Rocephin) and vancomycin with the same response.
Figures 1. On physical exam, the patient presented with a 1-cm hyperpigmented, well-demarcated, erythematous nodule on the left nasolabial fold with 2 additional superiorly placed 4-mm nodules.
The patient had onabotulinumtoxin A (Botox) in the past but denied the use of previous fillers. She denied any medical problems or allergies. On physical exam, the patient presented with a 1-cm hyperpigmented, well-demarcated, erythematous nodule on the left nasolabial fold with 2 additional superiorly placed 4-mm nodules (Figure 1). No discharge was present but the area was very tender to palpation. Incision and drainage was attempted and was unsuccessful. A bacterial culture was taken from the area which was negative for growth. An injection of 0.1 cc of 10 mg/cc intralesional triamcinolone was administered followed by 0.1 cc of hyaluronidase. The patient was also given cephalexin, 500 mg twice daily for 2 weeks. Upon follow-up 3 weeks later, the nodules resolved with no pain or swelling of the area. Only postinflammatory hyperpigmentation was noted. This will be addressed in her next appointment in 1 month (Figure 2).
Figures 2. Upon follow-up 3 weeks later, the nodules resolved with no pain or swelling of the area. Only postinflammatory hyperpigmentation was noted which will be addressed in her next appointment in 1 month.
Discussion
Soft tissue augmentation is a very desirable cosmetic procedure because it is fast, effective, and has relatively few complications. Because these procedures are increasing in numbers, the dermatologist should be familiar with the potential side effects and how to prevent and to treat them to improve patient safety and satisfaction. Early complications include edema, injection associated discomfort, bruising, and erythema, and they are usually self-limited, resolving within 1 week.2
Among the most serious acute complications are the ones related to vascular occlusion and nerve damage. They can be avoided with skillful technique and knowledge of the anatomic area where the procedure is performed.3
Another complication that can be seen after soft tissue augmentation is nodule formation. The etiology of nodules can can be divided into 2 categories: inflammatory and noninflammatory. Inflammatory nodules are either a result of an infection (biofilms) or foreign body granulomas. Noninflammatory nodules are secondary to the material injected too superficially and are evident shortly after the procedure. Hyaluronidase is the treatment of choice if the filler is HA. If other material is used, they can respond to vigorous massage or potentially extrusion of the material.4 Even though inflammatory nodules have 2 different etiologies, it can be difficult to elucidate its real cause. Foreign body granulomas are an uncommon complication of this procedure, with a rate of approximately 0.4% for HAs and 0.001% for calcium hydroxyapatite.5
Typically, they are treated with intralesional steroids and hyaluronidase with good resolution. If no clinical response is seen, a biofilm should be suspected and the patient should be placed on broad-spectrum antibiotics for a minimum of 4 weeks that include quinolones and macrolides.4 Biofilms are microenvironments that are formed around the filler by the adjacent bacteria, they elaborate extracellular matrix of exopolysaccharides that also include HA. The bacteria adhere to this matrix protecting it from antibiotics.6,7 When a biofilm is present, it usually will not render any result on the bacterial culture making the diagnosis difficult. Besides antibiotics, hyaluronidase should be used in these cases along with antibiotics to disrupt the protective microenvironment.7
Our Patient
In our patient, even though the nodules had been there for 2 months, they resolved with intralesional triamcinolone and hyaluronidase, making the diagnosis of noninflammatory nodules more plausible. To prevent biofilms, it is critical to undergo thorough cleaning of the patient’s face before the procedure, avoid injection in areas that may be swollen or infected, reduce the amount of needle sticks, and use the smallest sized needle.3
Soft tissue augmentation is a common procedure for dermatologists. Serious complications are very uncommon, however, knowledge of how to prevent and to treat them is paramount.
Dr Correa-Selm is a micrographic surgery and procedural dermatology fellow at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Dr. Rogachefsky is the Program Director of the ACGME-approved Micrographic Surgery and Procedural Dermatology Fellowship and practicing dermatologist at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Dr Lee is director of the ACGME-approved micrographic surgery and procedural dermatology fellowship and a practicing dermatologist at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Disclosure: The authors report no relevant financial relationships.
References
1. Plastic surgery statistics. American Society of Plastic Surgeons website. https://www.plasticsurgery.org/news/plastic-surgery-statistics. Accessed June 22, 2017.
2. Wagner RD, Fakhro A, Cox JA, Izaddoost SA. Etiology, prevention, and management of infectious complications of dermal fillers. Semin Plast Surg. 2016;30(2):83-86.
3. Bailey SH, Cohen JL, Kenkel JM. Etiology, prevention, and treatment of dermal filler complications. Aesthet Surg J. 2011;31(1):110-1121.
4. Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clin Cosmet Investig Dermatol. 2013;12(6):295-316.
5. Lolis M, Dunbar SW, Goldberg DJ, Hansen TJ, MacFarlane DF. Patient safety in procedural dermatology: Part II. Safety related to cosmetic procedures. J Am Acad Dermatol. 2015;73(1):15-24.
6. DeLorenzi C. Complications of injectable fillers, part I. Aesthet Surg J. 2013;33(4):561-575.
7. Beer K, Avelar R. Relationship between delayed reactions to dermal fillers and biofilms: facts and considerations. Dermatol Surg. 2014;40(11):1175-1179.
Lawrence Green, MD, reviews current biologic therapies available for psoriasis and shares his methods for selecting the appropriate biologic for patients.
Lawrence Green, MD, reviews current biologic therapies available for psoriasis and shares his methods for selecting the appropriate biologic for patients.
There are a number of factors that can increase your cosmetic patients’ satisfaction, including the types of information you provide after a procedure, if and when to schedule a follow-up visit and more.
There are a number of factors that can increase your cosmetic patients’ satisfaction, including the types of information you provide after a procedure, if and when to schedule a follow-up visit and more.
Angelo Landriscina, MD, reviewed important considerations dermatologists should keep in mind when treating LGBTQ patients with acne, such as discrimination and screening for psychological comorbidities.
Angelo Landriscina, MD, reviewed important considerations dermatologists should keep in mind when treating LGBTQ patients with acne, such as discrimination and screening for psychological comorbidities.
Over the past 2 years, the American Academy of Dermatology and the National Psoriasis Foundation have jointly released updated guidelines of care for patients with psoriasis. Test your knowledge of the recommendations with this pop quiz!
Over the past 2 years, the American Academy of Dermatology and the National Psoriasis Foundation have jointly released updated guidelines of care for patients with psoriasis. Test your knowledge of the recommendations with this pop quiz!
According to a recent interview with Jessica Johnson, MPH, what is a significant barrier to seeking mental health support among patients with atopic dermatitis?
According to a recent interview with Jessica Johnson, MPH, what is a significant barrier to seeking mental health support among patients with atopic dermatitis?
Which class of medications received a "general thumbs up" in the latest guidelines for atopic dermatitis management due to their efficacy and low cancer risk?
Which class of medications received a "general thumbs up" in the latest guidelines for atopic dermatitis management due to their efficacy and low cancer risk?
In a recent interview, Dr Jonathan Silverberg, mentioned the importance of understanding the strengths and weaknesses of new therapies. Which aspect did he particularly emphasize as crucial in clinical practice?
In a recent interview, Dr Jonathan Silverberg, mentioned the importance of understanding the strengths and weaknesses of new therapies. Which aspect did he particularly emphasize as crucial in clinical practice?
According to a recent interview with Dr Ilka Arun Netravali, what is the mechanism of action behind dupilumab that translates to effective suppression of atopic disease?
According to a recent interview with Dr Ilka Arun Netravali, what is the mechanism of action behind dupilumab that translates to effective suppression of atopic disease?
